'Burton is a 400-year-old version of that patient voice'

Robert Burton's Anatomy of Melancholy, first published in 1621, is a huge and innovative encyclopaedia of mental and emotional disorder, as understood in the late Renaissance. The Anatomy examines the causes and symptoms of melancholy (or, in modern terms, depression).

Burton emphasised melancholy as a common experience: 'Who is not a Foole, who is free from Melancholy?', answering his own question with 'all the world is mad, is melancholy, dotes'. Suggested remedies included good food and exercise, laughter, reading, music, and friends: 'be not solitary, be not idle'.

A scholar and clergyman in Christ Church, Oxford, Burton was one of the early users of the Bodleian Library and left many of the books in his own substantial collection to the Bodleian. Now an exhibition, running until 20 March, revisits the Anatomy, using objects from the Bodleian Libraries to highlight common experiences and connections over time.

One of the curators is Professor John Geddes, Head of the Department of Psychiatry at the University of Oxford. We asked Thomas Dixon, Professor of History at Queen Mary University of London, to have a conversation with Geddes about the book and exhibition.

So, John, perhaps you could begin with how you first encountered Robert Burton?
I'd qualified and gone into psychiatry training, in Sheffield. The place I lived, Hunter's Bar, had a lovely second hand bookshop at the end of the road. I used to go in and wander, and found this ancient Victorian three-volume version of The Anatomy of Melancholia. I had read about it when I was a house officer, because I've been reading another book, by Anthony Powell, A Dance to the Music of Time… a 12-volume book in which the protagonist is always doing something on the anatomy of melancholy, but you never really find out why.

So I bought The Anatomy of Melancholia and I just didn't know what to make of it. This huge book, which seems to be a review of melancholy, by an author who said that he was writing it to recover from his own melancholy. It was all over the place in the humanities, one of the most famous books of all time, always comes in the top 10, yet there was very little in the history of psychiatry about this book. That resonated with me… I used to take it along to journal clubs and try and get my colleagues interested.

Have you read the whole thing? I certainly haven't … it's quite off-puttingly enormous.
Even academic specialists in Burton will admit to not having read it in a conventional linear way. The only person who says they have is the author Phillip Pullman. We did an event when we launched the exhibition, and he had been asked by the Everyman Library to do an introduction, so he felt that he should really read it…

He's an exceedingly conscientious person!
Your answer hints at the fact that this exhibition is a direct conversation between psychiatry today, and Burton's text. What struck you, in terms of ways in which Burton 'anticipated' modern psychiatry?
This is the voice of someone who has a profound personal experience of the problem, and is writing to become expert on that problem, both for his own benefit and the benefit of others. I've become increasingly convinced over the last 20 years by the importance of the patient's voice in the way that we provide care but also in the way we direct research. Burton is a 400-year-old version of that patient voice: he tells the reader what he thinks a doctor should do, and how they should work with an individual patient.

That is very striking. It's not a medical treatise by a doctor, it's a patient narrative. Burton is giving voice to an experience – is it one you recognise as depression? Is melancholia depression, or a sort of distant ancestor or cousin?
Burton does focus on mood disorder, let's call it that, but again in a way that's quite modern. This broad, heterogeneous experience, which ranges from what we all experience as human beings, through to the most profound states that I'm happy to view as an illness. There's no one size fits all… there's this huge group of both causes, treatments, experiences. But it's a really central part of what being human is about, so very few people will not understand or be familiar with some of the experiences Burton is talking about, even if there's varying severity.

As a historian of emotions, in a way I'm coming at this from the opposite point of view – about what was different in the 17th century, and why melancholy maybe isn't the same as depression. There's that Burton quote in the exhibition: 'all the world is mad, is melancholy'. Of course, that's different from depression, where if you go to the DSM or some other standard definition of depression, you have to tick off five out of nine symptoms, and the idea is that a small proportion of the population have that. Is that a difference, the melancholy, for Burton, is universal?
Burton's conception of melancholy includes, but is not restricted to, what we would currently call depressive illness. But actually, if you look at the epidemiology of depression across humanity, it doesn't fall into this isolated group of depressive illness, and then nothing… there's a spectrum in the way we experience low mood. What DSM does is try to delineate the experience which would constitute a medical disorder. It's clearly going to be a very imperfect way of doing that.

I'm interested in how to demarcate an illness from an everyday emotion for all sorts of reasons, personal and professional. Some people are very insistent, really want to make that distinction: 'you might think you know what low mood is, but I've got clinical depression'. Whereas in my experience, my whole life has been on a continuum of emotions and moods, occasionally getting to the point where someone might say it was a disorder, but for me I don't see any line at all. For a clinician who had read Burton, how would they approach that question?
Within the book, there are descriptions that would quite clearly fit into something that would meet DSM criteria. But it's more expansive than that. A psychiatric epidemiologist, somebody looking at the distribution of the way humans experience low mood, would recognise what Burton's talking about pretty easily.

I was talking to the gardener and TV personality Monty Don, who has written very openly about his own experience of low mood. He was asking if depression is like respiratory infections: it can vary from a cold all the way through to severe infection that leads to us being ventilated in hospital. And I think that's right, in that we are just talking about the way humans talk about their own experiences. We still rely entirely on the subjective expression of mood when we're making the diagnosis. And that varies from something that we all experience from time to time and means that we're a bit below par, all the way through to things that are quite life threatening. I don't think there's any good evidence that there's a clear demarcation that we can point to reliably to say one is different from the other. It's on the basis of convention – 'when does this experience become a health problem?' And of course, the American DSM did that from the point of view of getting reimbursement from insurance agencies.

So hopefully, someone who goes to your exhibition will come away with a quite expansive sense of the range of experiences that might come under a broad umbrella of melancholia.
Yes, and also the approaches that may be helpful today. Burton goes through all the potential therapeutic approaches – everything from looking at your diet, to exercise, to sleep. We are rediscovering the fact there are lots of activities that might help us manage our own mood. Of course, this should be no surprise… presumably, the reason that we as humankind invented all these things is because they give us pleasure and help us cope in the face of the rather unfeeling universe.

Let me ask you about a couple of those specific treatments that are recommended by Burton, and implicitly by your exhibition. One is religion, which features in The Anatomy both as a problem and as a cure. There's religious melancholy, superstition and 'religious madness' of various kinds, and then there's a consolation of faith and religion. In the literature accompanying the exhibition, there's a reference to an Oxford psychiatry project today about faith and psychiatry, and your faith-oriented approaches. Does that work resonate with Burton's views on religion?
There's a general point in Burton that there's a balance to be achieved between something that in a certain amount is helpful, and if you do too much of it, it's unhelpful. Exercise is another example. Actually targeting research at understanding the dose effects of exercise and how they relate to individual people would be useful… our evidence base for exercise is pretty limited at the moment. And religion is probably along those lines too, I think that's an important insight.

Of course, Burton was a cleric. We've already got lots of insights from religion that might be helpful for mental health: again, in moderation. Mindfulness based cognitive therapy; the whole concept of mindfulness came out of religious practice. The project you mention, with Gulamabbas Lakha, brings together his ministry work as a Shaykh with his academic training in Psychology, to develop new ways of thinking about faith and therapy.

That also feeds into your point about thinking of Burton as an extended manifesto for listening to patients' own narratives. If a patient has a faith that is important to their understanding of themselves, then that will surely be important to their understanding of their mental condition, including mental illness and suffering. But let's say 50 years ago, would there have been a less holistic and harmonious relationship between psychiatry and religion?
For me, in Oxford, Burton has become quite symbolic for a number of us that are trying to work with colleagues in the humanities, social sciences, across the gardens, libraries and museums to broaden out the range of research that we do into things that might be helpful for people who have problems with mental health in one way or another… to actually develop the evidence base for things like social prescribing. Burton isn't dichotomising into a very biological base or a very psychological approach. He's perfectly happy to tolerate a multiplicity. That might not have always been there, if people tended to take ideological sides on what was important and what was not. 

We haven't talked about the exhibits other than Burton's text, but two jumped out at me because I know them quite well, I'm very fond of them… Mary Shelley's Journal of Sorrow that she wrote by hand after the death of her husband, Percy Shelley, and then there's also a reference to C.S. Lewis's A Grief Observed, which he wrote after his wife Joy died. They're both described as examples of scriptotherapy, as you call it, which is what Burton is doing as well – writing as therapy. To what extent is psychiatry rediscovering things that people have always known are good for them – reading and writing, going for walks, and so on – and calling them therapy? And is there any problem with that, if some people in the humanities might feel 'we know this is good, we've been doing this for centuries…'?
It's a worry, isn't it? But this isn't a way of annexing all those activities, it's a way of recognising the huge human benefits. I wouldn't for a minute try to say that all these things should be rebadged as therapy. It's about how these activities might be helpful, both in a preventive way as hugely powerful ways of helping us navigate our difficult lives, and for some people with degrees of low mood or depression, they might be quite effective treatments, or could be developed as such. You might be able to pick out the mechanisms by which some of these practices help and map them on to people's problems quicker.

There's an explosion of interests in all these activities. In bookshops, some of the biggest sections are self-help books, covering everything from bird therapy, poetry therapy, nature therapy… Where did you start? Do people have to have to go through everything? Or is there a way of saying, 'In your case, you need something that is going to provide something for your reward systems'?

It comes back to the individual patient, which is where you started, Burton as a particular human being with a particular narrative. I live in the countryside, I like nature, it might be very sensible to prescribe that I try and get out more. But for someone who's not the slightest bit interested in nature, but loves art, you might prescribe something different.
To end: Is there an object, text or image in the exhibition that you particularly love, or that you were surprised by?
Those texts you've actually drawn out – Shelley, C.S. Lewis – were great finds. But right at the beginning of the exhibition we have a portrait of Burton, on loan from Brasenose College. The thing that almost makes me fall to my knees is standing in front of that and looking into his eyes, which are blazing out, gazing down the whole room. It's an obvious one, but it is so important. It's the 400th anniversary of his book and it is still just as revered, just as influential. Remarkable.

For information, see visit www.bodleian.ox.ac.uk/about/media/melancholy-a-new-anatomy